Personal Details Form

Instructions

Please complete all the relevant sections. You should complete the form when you start work with QMUL, and if you later needto update any of the information.If you are starting work with QMUL, send/emailthe completed form to the HR Departmentalong with your signed offer of employment/email confirmation of acceptance. QMUL requires all the information on this form to (a)set you up on its payroll system; (b) to complete its HESA return (which isa condition of funding); and (c) to comply with tax regulations. If any required fields are missing for new starters, QMUL cannot pay you.

1. Purpose of Form
New appointment/making a claim for payment / I would like to amend/update my current details
2. QMUL School/Institute & Centre/Department
3. Personal Details(complete all sections)
Surname / Title
First Name(s)
Other Forenames
Known As
Former Name (if applicable) / Date of Birth (dd/mm/yyyy)
Gender / Male / Female
4. Your Contact Details (You must complete at least line 1 and 2 and the postcode)
Home address / Line 1
Line 2
Line 3
Line 4 / Postcode
Home phone / Mobile
5. Emergency Contact
Name / Relationship
Address / Post code
Home phone / Mobile / Work
6. Rehabilitation of Offenders Act (1974)
Many posts involving contact with patients/children are exempt from the Rehabilitation of Offenders Act (1974). You are therefore required to declare any convictions and pending prosecutions. Any information you supply will be treated as confidential and will not necessarily prejudice your application
I have not been convicted of any criminal offence, spent or otherwise.
I have been convicted of a criminal offence, spent or otherwise. Please give details below.
7. Income Tax details(complete all sections)
Have you had a P45? / Yes
To be forwarded / National Insurance Number
If you have one, you must bring your P45 with you to the HR Department on your first day of employment. If you do not do so, you must complete the following section.
Please read the following three statements carefully and tick the one box that applies to you.
A / This is my first job since last 6 April and I have not been receiving taxable Jobseeker’s Allowance or taxable Incapacity Benefit or a State or Occupational Pension.
B / This is now my only job, but since last 6 April I have had another job, or have received taxable Jobseeker’s Allowance or Incapacity Benefit. I do not receive a State or Occupational Pension.
C / I have another job or receive a State or Occupational Pension.
8. UK Student Loan- tick the appropriate box if you have a UK Student Loan and are not repaying directly through your bank or building society
Plan 1 UK Student Loan
• You lived in Scotland or Northern Ireland when you started your course, or
• You lived in England or Wales and started your course before September 2012

Plan 1
Plan 2 UK Student Loan if you lived in England or Wales and started your course on or after 1 September 2012.
Plan 2
9. Bank/Building Society details(complete all sections)
Please note: we are unable to pay into a non-UK bank account.
Please enter below details of the account into which you wish your salary to be paid.
Name of UK Bank/Building Society
Address
Sort code / Account number (8 digits only )
Roll number (if needed by building society)
10. Pension details(complete all sections)
IMPORTANT - You will automatically be entered into the relevant pension scheme.
PLEASE NOTE IF YOU CHOOSE TO OPT OUT THE FORM MUST BE COMPLETED ON OR AFTER YOUR START DATE AND WITHIN 3 MONTHS TO BE ELIGIBLE FOR A REFUND OF YOUR CONTRIBUTIONS.
An opt out form can be downloaded from the relevant links below:
Grades 1 -3:
Grades 4 and above:
Please email your completed form to:or send to the HR Office, Mile End
Are you currently a member of any of the following pension schemes?
Do you wish to continue in that scheme?
*Please request SD65 form from / NHS
Yes* / USS
Yes / SAUL
Yes
11. Equal opportunities (complete all sections)
Please note this section is for monitoring purposes and to assistQMULin promoting equality and diversity.
QMUL confirms its commitment to a policy of equal opportunities in employment in which individuals are selected, trained, appraised, promoted and otherwise treated on the basis of their relevant merits and abilities and are given equal opportunities within QMUL. To enable us to monitor the operation of this policy, it is necessary to collect relevant information from all job applicants and employees.
Please mark with a tick the box(es) below which most closely describe you (codes are for use by HR).
Ethnic Background
White or White British
British (11)
Other White background (19)
Black or Black British
Caribbean (21)
African (22)
Other Black background (29)
Asian or Asian British
Indian (31)
Pakistani (32)
Bangladeshi(33)
Chinese(34)
Other Asian Background (39)
Mixed
White and Black Caribbean (41)
White and Black African(42)
White and Asian(43)
Other Mixed background (49)
Other
Gypsy or Traveller (15)
Arab (50)
Other Ethnic background (80)
Prefer not to say(98)
Religion
No Religion (01) / Jewish (11)
Buddhist(02) / Muslim(12)
Christian (03) / Sikh (13)
Hindu (10) / Spiritual (14)
Other (80) / Prefer not to say (98)
Nationality(please confirm nationality below)
Sexual Orientation
Bisexual (01) / Gay Woman / Lesbian (03) / Other (05)
Gay man (02) / Heterosexual/ Straight (04) / Prefer not to say (98)
Disability
Under the Equality Act 2010, a person has a disability 'if they have a physical or mental impairment, and the impairment has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities'.
Do you have a disability? / Yes / No (00) / Prefer not to say (97)
Nature of any disability
Specific learning disability (such as dyslexia or dyspraxia) (51)
General learning disability (such as Down's syndrome) (52)
Social/communication impairment such as Asperger's syndrome/other autistic spectrum disorder) (53)
Long-standing illness or health condition (such as cancer, HIV, diabetes, chronic heart disease, or epilepsy) (54)
Mental health condition (such as depression or schizophrenia) (55)
Physical impairment or mobility issues (such as difficulty using arms or using a wheelchair or crutches) (56)
Deaf or serious hearing impairment (57)
Blind or a serious visual impairment uncorrected by glasses (58)
A disability, impairment or medical condition that is not listed above(please specify in the box below): (96)
If you require support and/or reasonable adjustments please contact your line manager or the Diversity Team () as soon as possible.
12. Previous Employment before QMUL (not required for casual/one-off payment staff)
If you have previously worked at another Higher Education Institute in the UK, please give details of your HESA Staff Identification Number (13 digit number – your previous institution will be able to provide this for you).
HESA Staff Identification Number
Please tick the box which most closely describes your previous employment or occupation before entering employment with QMUL. Where a break in continuous service occurs and an individual has not been employed elsewhere during the break, code 21 'Not in regular employment' must be returned in this field.
Another Higher Education Institute in UK (01)
Higher Education Institute in an overseas country (including other EU countries) (02)
Other Education Institute in UK (03)
Other Education Institute in an overseas country (including other EU countries) (04)
Student in UK (07)
Student in an overseas country (including other EU countries) (08)
NHS/General medical or general dental practice in UK (09)
Health Service in an overseas country (including other EU countries) (10)
Other Public Sector in UK (11)
Private Industry/Commerce in UK (12)
Self-Employed in UK (13)
Other Employment in UK (14)
Other Employment in an overseas country (including other EU countries) (15)
Working in a research institute (private) in the UK (16)
Working in a research institute (private) in an overseas country(17)
Working in a research institute (public) in the UK (18)
Working in a research institute (public) in an overseas country (19)
Working in the voluntary sector (20)
Not in regular employment (21)
If your last employment was with a University within the UK or if you have at any time held such an appointment at a UK University please complete the section below. Give the most recent previous institution.
Name of UK University:
13.Current Academic Discipline (not required for casual/one-off payment staff)
Please enterbelow details of your current academic discipline(s) – academic staff only
Academic Discipline 1
Academic Discipline 2
14. Highest Qualification Held to Date(not required for casual/one-off payment staff)
Please tick the box which most closely describes your highest qualification to date. In cases where it is unclear which qualification is the 'highest' enter the code that is closest to 01 'Doctorate'.
Doctorate (01)
Other Higher Degree (includes Masters)(02)
PGCE (03)
Other Postgraduate qualification (including professional) (09)
First Degree(11)
First Degree with Qualified Teacher Status (QTS) (12)
Other qualifications at first degree level (including professional) (19)
Diploma of Higher Education(21)
HND/HNC (22)
Other undergraduate qualification (including professional) (29)
A level, Scottish Higher or equivalent (NVQ/SVQ Level 3) (31)
O level/GCSE or equivalent (NVQ/SVQ Level 2) (32)
Other qualification (includes any overseas qualification that is not listed)(97)
No qualifications held (98)
15. Academic Teaching Qualification(not required for casual/one-off payment staff)
Please tick the box which most closely describes your academic teaching qualification/teaching expertise (this section should only be completed by academic staffwho are ‘Teaching Only’ or ‘Teaching & Research’)
Successfully completed an institutional provision in teaching in the higher education sector accredited against the UK Professional Standards Framework (01)
Recognised by the HEA as an Associate Fellow(02)
Recognised by the HEA as a Fellow(03)
Recognised by the HEA as a Senior Fellow (04)
Recognised by the HEA as a Principal Fellow (05)
Holder of a National Teaching Fellowship Scheme Individual Award (06)
Holder of a PGCE in higher education, secondary education, further education, lifelong learning or any other equivalent UK qualification (07)
Accredited as a teacher of their subject by a professional UK body(08)
Other UK accreditation or qualification in teaching in the higher education sector(09)
Overseas accreditation or qualification for any level of teaching(10)
No academic teaching qualification held (99)
Please note any individual who holds any Teaching English as a Foreign Language qualification should tick the above box – ‘No academic teaching qualification held’
16.Current Clinical and Healthcare Specialty(not required for casual/one-off payment staff)
Please enter details below of your current Clinical Sub-Specialty andyour Healthcare Professional Specialty. If you have more than one specialty please enter the additional details in the relevant box(es) below.
Clinical Sub-Specialty 1
Clinical Sub-Specialty 2
Clinical Sub-Specialty 3
Healthcare Professional Specialty 1
Healthcare Professional Specialty 2
Healthcare Professional Specialty 3
17. Professional Registration for Staff in Medical/Dental/Health and Social Care Professions
Please tick the appropriate boxes and give any further information required:
General Medical Council (GMC) Registered (01)
General Dental Council (GDC) Registered (02)
GMC/GDC Registration Number: / Expiry Date:
National Training Number:
Nursing and Midwifery Council (NMC) Registered (06)
NMC Registration Number:
Health and Care Professions Council (HCPC): excluding social workers in England(07)
Health and Care Professions Council (HCPC): social workers in England (08)
HCPC Registration Number :
General Optical Council (GOC) Registration (03)
Pharmaceutical Society of Northern Ireland (PSN) Registration (05)
Scottish Social Services Council (SSSC) Registration (09)
Care Council for Wales (CCW) Registration (10)
Northern Ireland Social Care Council (NISCC) Registration (11)
General Osteopathic Council (GOsC) Registration (12)
General Chiropractic Council (GCC) Registration (13)
Royal College of Veterinary Surgeons (RCVS) (14)
General Pharmaceutical Council (GPhC) (15)
18.Consent to Process Sensitive Data
To comply with the Data Protection Act 1998, QMUL needs your permission to hold and use personal information that could be considered sensitive. It is the Data Controller of this information under the Act. This information will be used for any purpose relevant to the effective management of QMUL, including but not limited to the following categories:
  1. Checking suitability and fitness to work
  2. Administration of Human Resources and Payroll functions
  3. Administration of sick pay and sick leave schemes
  4. Administration of maternity leave and maternity leave pay schemes
  5. Monitoring equality and diversity
  6. Managing duties and obligations under the Equality Act
  7. Criminal records
  8. Effective joint-working with partner NHS Trust
  9. Administration of statutory returns to the Higher Educational Statistical Agency (HESA). Every year, we send some of the information we hold about you to the Higher Education Statistics Agency (HESA). This forms your HESA Staff Record which does not contain your name or contact details. The data held about you by HESA is anonymised and is a subset of that held on you by QMUL. The HESA Staff Collection Notice should be read by all staff.
Any data subject requests should be addressed in first instance to the Records & Information Compliance Manager.
19. Declaration(please tick all of the boxes below)
I confirm that all the information about me on this form is correct and I will inform HR of any changes.
If I have access to MyHR I understand that is expected that I keep my personal details up to date by using this self-service system. Queen Mary University of London (QMUL)will also from time-to-time send employees a copy of the details held on computer in order to keep this information up-to-date.
I understand that any misleading information or deliberate omissions will be regarded as grounds for withdrawal of any offer, or subsequently, for disciplinary action, which could lead to dismissal.
I confirm that I have read the terms and conditions relating to pension and its implications.
Further, I give my consent for QMULto hold and use sensitive personal information about me provided:
  1. the information is used only for the purposes set out in section17of this form; and
  2. QMULcomplies with its obligations and duties under the Data Protection Act 1998.

Full Name
Please note you only need to sign this form if you intend to return it by post/provide us with a hard copy.
Signature / Date

1Oct 2017